Difficult Patients: Exploring the Patient Perspective

1. Difficult Patients: Exploring the Patient Perspective Wisconsin Research & Education Network September 21, 2012 Caitlin Regner, BS, student researcher Jennifer Edgoose, MD/MPH, Principal Investigator (Jennifer.edgoose@fammed.wisc.edu)

2. Who are “difficult” patients? What characteristics make a patient “difficult”? • Mental health disorders • Multiple symptoms • Chronic pain • Functional impairment • Unmet expectations • Lower satisfaction with care • High users of health care services Dr. Tom O’Dowd coined the term “heartsink patient” BMJ, 1988

3. Who defines them? Providers with: • Greater perceived workload • Lower job satisfaction • Poorer psychosocial scores • Less experience • 9 versus 12 years (p=0.0002)

4. Why not just ignore them? Because we can’t. At least 1 in 6 patients are “difficult” and so we see them every day. Photo by Chat-Lunatique

5. Research Question If physicians find their relationships with difficult patients to be frustrating, if not overwhelming, … …do difficult patients also find these relationships to be equally challenging?

6. Study Design • Prospective cohort study • Patient inclusion criteria: • Patients of 12 family medicine residents • 18 years or older • Patients were assigned coded numbers. • Patients were notified of study at clinic check-in. • Residents indicated difficult patients for that day • Only coded numbers were submitted to maintain patient confidentiality

7. Study Design • Survey completed through • Option 1: interview by medical student • Option 2: written self completion • Basic Demographic Data collected: • Gender • English speaking or non-English speaking • Ethnicity/Race • Education Level • 6 Questions developed • Graded on a Likert Scale from 1-7 • Comments optional for each question

8. Patient Questionnaire • In general, how easy is it for you to talk with your doctor? • How easy do you think your medical problems are for your doctor to deal with? • How much control do you feel you have over your health care decisions? • How often do you feel your doctor addresses your concerns during your appointments?

9. Patient Questionnaire • How often does your doctor ask you non-medical questions to help understand your concerns during your appointments? (e.g. What is your occupation or job?; Where are you from?; Who do you live with?; Do you have access to a car?; Do you have problems paying for your medicines?) • What can we change to do a better job of taking care of you at our clinic?

10. Results: Study enrollment profile Total Difficult Patients: 19%

11. Results:Comparison of survey responses based on difficulty status a Two sample t-test comparison of means; *p < 0.05

12. Results: Difficult Patient Comments • “I do whatever she tells me. There’s no point in coming in if you don’t listen to your doctor.” • “She is very worried about my health.” • “Is very willing to take time. I never feel rushed.” • “I LOVE DR. X!”

13. Results: Non-Difficult Patient Comments • “Dr. X asks excellent questions and is open to your questions.” • “My mom is 95 and speaks Spanish only, so there are some communication issues.” • “Take care of the problems that I tell you are wrong, not what you think is wrong.” • “Fewer questionnaires. This one wasn’t too bad.”

14. Results: Gender profile of the study participants a Chi-square statistics

15. Results: Comparison of survey responses based on gender aTwo sample t-test comparison of means; *p < 0.05; **p < 0.01

16. Results: Racial profile for study participantsa a 7 subjects did not select a race category b Chi-square statistics

17. Results: Comparison of survey responses based on race a One-way Analysis of Variance (ANOVA) * p < 0.05; *** p < 0.001

18. Results: Multivariate Analysis of Gender, Race, Education and Difficulty • Genderis a significant predictor for questions 1, 2 and 3 (p = 0.008; 0.015 and 0.046 respectively). Thus males report a harder time talking with their doctor; think they are more difficult for their doctor; and feel less in control of their health care decisions. Difficulty is NOT a predictor for these questions surrounding patient-doctor communication.

19. In summary • While providers of difficult patients are frustrated, patients are not. • This is inconsistent with a previous study showing difficult patients are “less satisfied” than non-difficult patients but this study by Hinchey and Jackson applied the RAND-9 survey which looks at satisfaction from a standpoint not specific to the doctor-patient relationship but includes satisfaction about wait times, clinic location, phone scheduling, and other more clinic-process oriented inquiries. Our survey may therefore explains why these challenging patients are more likely to keep returning to their providers.

20. What does this mean? • We speculate that provider frustration lies in the incongruity of patient and physician perspectives about their relationship. • Is the world view of patient and provider discordant due to educational differences, language and/or personality disorders? • Schafer and Nowlis found that when analyzing 21 difficult patients, 33% of difficult patients had at least one personality disorder, particularly dependent personality disorders. • Do providers feel guilt about their feelings toward their patients and (over) compensate with extra time and energy?

21. Limitations of the study • Underpowered to statedefinitively : • Difficult versus non-difficult patients do not feel differently about their ability to communicate effectively with their doctors. • Limited number of control variables • only controls for demographics • no socioeconomic or health problem indicators • Single clinic surveyed which may not be generalizable to a broader population

22. Future research • Ethnicity requires further exploration due to low sample size; only 6 Hispanic patients participated in this study. • Education level is undergoing further analysis

23. US Photo by Chat-Lunatique THEM A study is underway exploring a tool to assist providers in working with difficult patients. Photo by giveawayboy

24. Thank you! • Northeast Clinical Staff and Residents • Jon Temte – SSRCA Director • Mary Beth Plane – Director, DFM Research Services • Larissa Zakletskaia – Data Base Administrator (DFM)

25. Bibliography • Hahn SR, Kroenke K, Spitzer RL, Brody D, Williams JB, Linzer M, de Gruy FV 3rd. The difficult patient: prevalence, psychopathology, and functional impariment. J Gen Internal Medicine. 1996 Jan; 11(1):1-8. • Mathers N, Jones N, Hannay D. Heartsink patients: a study of their general practitioners. BrJ Gen Pract. 1995;45(395):293-296. • Hahn SR. Physical Symptoms and Physician-Experienced Difficulty in the Physician-Patient Relationship. Ann Internal Med. 2001 May 1; 129(9 pt. 2):897-904. • Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic. Arch Intern Med. 1999;159:1069-1075. • Hahn SR, Thompson KS, Wills TA et al. The difficult doctor-patient relationship: somatization, personality and psychopathology. J ClinEpidemiol. 1994:47:647-657. • Hinchey, SA, Jackson AL. A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes. J Gen Intern Med. 2011 Jan 25. • Ashworth CD, Williamson P, Montano D. A scale to measure physician beliefs about psychosocial aspects of patient care.SocSci Med. 1984;19:1235-1238. • An PG, Rabatin JS, Manwell LB, Linzer M, Brown RL, Schwartz MD Burden of difficult encounters in primary care: data from the minimizing error, maximizing outcomes studey. Arch Int Med. 169:410-414. • Edgoose JYC. Finding the person behind the patient. Presentation given at the Wisconsin Psychological Association 2012 Annual Convention, April 2012. • Schafer S, Nowlis DP. Personalisty disorders among difficult patients. Arch Fam Med. 1998;7:126-129.

26. Questions? Photo by giveawayboy